Provider Demographics
NPI:1841366630
Name:SHAW, DANTE SANDLIN (PHD)
Entity type:Individual
Prefix:
First Name:DANTE
Middle Name:SANDLIN
Last Name:SHAW
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 LAUREL LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4317
Mailing Address - Country:US
Mailing Address - Phone:404-556-4226
Mailing Address - Fax:770-963-7490
Practice Address - Street 1:750 LONGLEAF BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30045-8459
Practice Address - Country:US
Practice Address - Phone:404-556-4226
Practice Address - Fax:770-963-7490
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0001314103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA68BBGFZMedicare ID - Type Unspecified